CONCUSSION MANAGEMENT 2014

WHAT WE’RE LEARNING

Rick Zappala, ATC January 12, 2014 Mashantucket, CT

WHY ARE WE HERE?

Recent concussion news

Review concussion guidelines

State & sports association legislation

How are we evaluating concussions?

Some “concussions” are really hard to find

Return to play

Return to learn

Concussion protocols - Do you have one?

What are some of the things you are doing?

WHY ARE WE HERE?

CONCUSSIONS IN THE NEWS

“When I was playing we didn’t know from concussions. We knew smelling salts and that was it. No one talked concussions. (Joe Namath 9/9/13)

NFL, players reach whopping $765M settlement in concussion case (http://sports.yahoo.com/blogs/nfl-shutdown-corner/nfl-players-reach-whopping-765m-settlement-concussion-case-165508435--nfl.html)

CONCUSSIONS IN THE NEWS

… that high school football players were almost twice as likely to have concussions as their collegiate counterparts. (Nadia

Kounang, CNN, 10/31/13)

Damon Janes, a 16-year-old junior running back for the Brocton (N.Y.) High School varsity football team, died on Monday, 9/16/13 as a result of injuries suffered from a helmet-to-helmet hit. (http://bleacherreport.com/articles/1776791-high-school-

football-player-dies-after-helmet-to-helmet-collision)

2013

Dylan Jeffries, Lost Creek WV, 10/13 Chad Stover, Tipton MO, 10/13 Charles Yovella, Hopi HS, AZ, 11/13

WHERE HAVE WE COME FROM?

Past attitudes Only a “ding”

“Bell rung”

Lack of understanding What is really going on in the

brain?

Rush to RTP Coaches

Athletes

Parents

“THIS CONCUSSION STUFF IS BS!” Field hockey official 10/17/13

WHAT???? How many each year?

1.6 to 3.8 million brain injuries each year in US (AAN)

300,000 sports related concussions (CDC)

Majority are adolescent & pediatric (AAP)

TABLE 1 Concussion Rates in High School Sports Sport Injury Rate, per 1000 A/E Football 0.47–1.03 a,b Girls’ soccer 0.36 a Boys’ lacrosse 0.28–0.34 c,d Boys’ soccer 0.22 a Girls’ basketball 0.21 a Wrestling 0.18 a Girls’ lacrosse 0.10–0.21 c,d Softball 0.07 a Boys’ basketball 0.07 a Boys’ and girls’ volleyball 0.05 a Baseball 0.05 a a Data from Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42(4):495–503. b Data from Guskiewicz KM, Weaver NL, Padua DA, Garrett WE. Epidemiology of concussion in collegiate and high school football players. Am J Sports Med. 2000;28(5):643–650. c Data from Lincoln AE, Hinton RY, Almqueist JL. Head, face, and eye injuries inscholastic and collegiate lacrosse: a 4-year prospective study. Am J Sports Med. 2007;35(2):207–215. d Data from Hinton RY, Lincoln AE, Almquist JL. Epidemiology of lacrosse injuries in high school-aged girls and boys: a 3-year prospective study. Am J Sports Med. 2005;33(9): (PEDIATRICS Volume 126, Number 3, September 2010)

WHAT IS A CONCUSSION?

Concussion is a brain injury and is defined as a complex patho-physiological process affecting the brain, induced by biomechanical forces.

McCrory P, et al. Br J Sports Med 2013;47:250–258. doi:10.1136/bjsports-2013-092313

A disruption of the normal neurological function of the brain, or

a brain injury that is caused by a sudden blow to the head or to the body. The blow shakes the brain inside the skull, which temporarily prevents the brain from working normally.

http://www.webmd.com/brain/tc/traumatic-brain-injury-concussion-overview

WHAT IS A CONCUSSION?

They can range from mild to severe and can disrupt the way your brain normally works.

They can happen even if you are not “knocked out.”

Even a “ding” or having your “bell rung” can be serious.

You can’t see a concussion. Signs & symptoms can show

up right after the injury, or can take hours, days or weeks to appear.

CONCUSSION vs mTBI

4th Consensus statement 2012

Often used interchangeably

Concussion is a subset of mTBI

Concussion used in most documents

Let’s call it what it is

INCREASED PUBLIC ATTENTION

Media coverage

Legislative efforts

Rules changes

STATE LEGISLATION

49 states & Washington DC have concussion legislation http://www.lawatlas.org/preview?dataset=sc-reboot http://www.momsteam.com/health-safety/majority-of-states-have-youth-sports-concussion-safety-laws

Common provisions Educate Recognize Remove Refer to medical care Rest Return after healed

NY (2011) Must be symptom free for at least 24 hours and cleared by a licensed physician. The school’s chief medical officer will make the final decision on return to activity including

physical education class and after-school sports. 6 step RTP protocol

MA ( 2010) The student shall not return to play unless and until the student provides medical clearance and authorization as

specified in 105 CMR 201.011.

NJ (NJSIAA 2010) Evaluation by physician or other license health care provider

CT (CIAC 2010) 5 R’s of concussion management

ME No return to play until cleared by licensed neurologist or athletic trainer

NH RTP with permission of health care provider

VT Return with clearance from a health care provider

RI Written authorization by a licensed physician

PA RTP with clearance by a physician, athletic trainer or neuropsychologist

DE RTP with medical clearance conforming to association regulation

STATE LEGISLATION

High school athletic associations

AT associations

Official’s associations

STATE/LOCAL ASSOCIATIONS

Momsteam.com

LEAGUE POLICIES

NFL (2011)

Rule changes to reduce hits to the head

Every team will be required to use the same neurologic test to determine on the field whether an injured player may return to the game.

"The NFL Sidelines Concussion Exam" is a battery of simple tests evaluating concentration, basic thinking skills and balance. It also includes a questionnaire that asks about concussion symptoms. (Dr. Richard Ellenbogen , MD, 2/25/11)

NBA

– New policy that requires players to pass a series of test before returning to play

NHL

– any player who exhibits concussion symptoms resulting from a play must be removed from the game and taken to a quiet place in the locker room area for an evaluation by a physician (WTEN.com 3/14/11)

NATIONAL ASSOCIATIONS NCAA (2010)

Institution must have a concussion management plan A student-athlete who exhibits signs, symptoms or behaviors consistent with a

concussion shall be removed from practice or competition and evaluated by an athletics healthcare provider with experience in the evaluation and management of concussions. Student-athletes diagnosed with a concussion shall not return to activity for the remainder of that day.

RTP by team physician Student-athletes receive concussion education Sign a statement accepting responsibility to report injuries Football “targeting rule”

NFHS (01/2011) Follow the “Heads Up” 4-step Action Plan.

Remove the athlete from play. Ensure that the athlete is evaluated by an appropriate health-care professional. Inform the athlete’s parents or guardians about the possible concussion and give them

information on concussion. Keep the athlete out of play the day of the injury and until an appropriate health-care

professional says he or she is symptom-free and gives the okay to return to activity After medical clearance, RTP should follow a step-wise protocol with provisions for delayed

RTP based upon return of any signs or symptoms.

AMERICAN ACADEMY OF NEUROLOGY

Recommendations 1. Any athlete who is suspected to have suffered a concussion should be

removed from participation until he or she is evaluated by a physician with training in the evaluation and management of sports concussions

2. No athlete should be allowed to participate in sports if he or she is still experiencing symptoms from a concussion.

3. Following a concussion, a neurologist or physician with proper training should be consulted prior to clearing the athlete for return to participation.

4. A certified athletic trainer should be present at all sporting events, including practices, where athletes are at risk for concussion.

5. Education efforts should be maximized to improve the understanding of concussion by all athletes, parents, and coaches.

Position Statement History Approved by the AAN Sports Neurology Section, Practice Committee, and

Board of Directors October 2010 (AAN Policy 2010-36). Up dated March 2013 supporting legislation & education

WHAT DOES THIS MEAN TO US ON THE SIDELINES?

Know YOUR state laws

Know concussion management guidelines

Be supported by your supervising physician

Educate administrators, coaches, parents, athletes on the laws & guidelines

DO NOT return a concussed athlete back to play

Be confident in your decision – it is the right thing to do

WHAT DO WE DO?

Recognize if there is a concussion

Signs & symptoms

Other possible causes Hypoglycemia

Illness

Poor conditioning

etc

Don’t be mislead Nobody WANTS it to be a

concussion

UNDER TREATMENT VS. OVER TREATMENT

Need to do what is right for the athlete

Athletes, parents, coaches concerns

When in doubt sit them out

USE MULTIPLE EVALUATION TOOLS

Signs/Observations Symptoms

Graded Symptom Checklist (GSC)

Orientation Maddocks Score Time, date, etc

Memory Word recall

Concentration Number recall, count back by 7 Months in reverse order

Postural Stability Balance Error Scoring System

(BESS)

Coordination Rhomberg, Stork tests

YOUR EVALUATION TOOLS

Symptom Checklist (GSC)

Sideline Assessment of Concussion Exam (SAC)

BESS

Sport Concussion Assessment Tool (SCAT3)

Child SCAT3

Glasgow Coma Scale

King-Devick Test

Neuropsych testing

SYMPTOMS

Blurred vision

Dizziness

Drowsiness/Fatigue

Feel “in a fog”

Feel “slowed down”

Sadness

Headache

Ringing in Ears

Nausea

Sensitive to Noise

Sensitive to Light

Numbness (Any where)

Vomiting

Disoriented

Poor Balance/Coordination

Weakness (Neck, arm, etc)

Unable to Concentrate

Confused or Distracted

Nervousness

Irritability/Anger

Difficulty remembering

GRADING THE SYMPTOMS

HEAD INJURY GRADED SYMPTOM CHECKLIST

INDICATE THE SEVERITY OF EACH SYMPTOM USING THE FOLLOWING SCALE

GRADING SCALE: 0 - NONE 1-TRACE 2-MILD 3-MODERATE 4-SEVERE 5-MOST SEVERE

(Grading by the patient.)

Symptom At Time

Of Injury

Date _________

____ Min/hrs

Post-Injury

Date _________

____ Min/hrs

Post-Injury

Date _________

____ Min/hrs

Post-Injury

Date ________

___ Min/hrs

Post-Injury

Date ________

___ Min/hrs

Post-Injury

Blurred Vision

Dizziness

Drowsiness/Fatigue

Feel "in a fog"

SIGNS & OBSERVATIONS

Look for SIGNS Observable

Vacant stare/Glassy eyed Clutching/Holding head Pupil response Not making sense Difficulty speaking Loss of consciousness Posturing

More Sensitive Indicators Orientation Memory Concentration Balance

LOC IS NOT AN GOOD INDICATION OF CONCUSSION SEVERITY

LOSS OF CONSCIOUSNESS

“THE EYES ARE THE WINDOW TO THE SOUL”

Matthew 6, 22-23

Pupil Response

Nystagmus

EYE MOVEMENT

Saccades

H-Test

EYE MOVEMENT

Ocular Convergence

Gaze Stability

ORIENTATION EVALUATION

Orientation (1 point each) Month 0 1

Date 0 1

Day of Week 0 1

Year 0 1

Time (within 1 hr) 0 1

Total Score / 5

ORIENTATION EVALUATION

Maddocks Score

What venue are we at today?

Which half is it now?

Who scored last?

What team did we play last?

Did your team win the last game?

Word Recall (1 pt each) Cat 0 1

Florida 0 1

School 0 1

Ocean 0 1

Book 0 1

Immediate Trials (3) Total Score / 15

Delayed Trial Total Score / 5

MEMORY EVALUATION

Concentration Reverse Digits (Go to next string length if correct on first trial. Stop if incorrect

on both trials. 1 pt for each string length)

1 - 4 - 2 6 - 5 - 8 0 1 6 - 8 - 3 - 1 3 - 4 - 8 – 1 0 1 4 - 9 - 1 - 5 - 3 6 - 8 - 2 - 5 - 1 0 1 3 - 7 - 6 - 5 - 1 - 9 9 - 2 - 6 - 5 - 1 - 4 0 1

Months in reverse order (1 pt for entire sequence) Dec - Nov - Oct - Sep - Aug - Jul – Jun - May - Apr - Mar - Feb – Jan

Concentration Total Score / 5

Others: Count backward from 100 by 7s, Days of the week

backwards, etc

CONCENTRATION EVALUATION

BALANCE EVALUATION

Balance Error Scoring System Record The Number Of Errors For Each 20 Second

Stance

Recordable Errors Hands Lifted Off Iliac Crests

Opening Of Eyes

Step, Stumble Or Fall

Moving Into › 30° Hip Flex Or Abd

Remaining Out Of Test Position For › 5 Sec

B.E.S.S.

B.E.S.S.

DATE

___________ DATE

___________ DATE

___________ DATE

___________ DATE

__________

_

DATE

_________

__

SURFACE/

STANCE At Time

Of Injury _____

Min/hrs

Post-Injury

______ Hrs

Post-Injury ______ Hrs

Post-Injury ______ Hrs

Post-Injury ______ Hrs

Post-Injury

FIRM/

DOUBLE LEG

FIRM/

TANDEM

FIRM/

SINGLE LEG

FOAM/

DOUBLE LEG

FOAM/

TANDEM

FOAM/

SINGLE LEG

TOTAL SCORE

BALANCE ASSESSMENT

Commercial assessment & training

Vestibular training

http://www.4securehealth.com/

COORDINATION

Rhomberg Test

Stork Test

Heel to toe walk

Light exercise

Sit up, push up, squats

Postural change

Running

POSTURAL CHANGES/ PROVOCATIVE ACTIVITY

GLASGOW COMA SCALE The test measures the motor

response, verbal response and eye opening response with the following values:

The final score is determined by adding the values of I+II+III

I. Motor Response 6 - Obeys commands fully 5 - Localizes to noxious stimuli 4 - Withdraws from noxious stimuli 3 - Abnormal flexion, i.e. decorticate posturing 2 - Extensor response, i.e. decerebrate posturing 1 - No response

II. Verbal Response 5 - Alert and Oriented 4 - Confused, yet coherent, speech 3 - Inappropriate words and jumbled phrases consisting of words 2 - Incomprehensible sounds 1 - No sounds

III. Eye Opening 4 - Spontaneous eye opening 3 - Eyes open to speech 2 - Eyes open to pain 1 - No eye opening

CONCUSSION ASSESSMENT TOOLS

SCAT 3

SCAT 3 CHILD

CRT (Concussion Recognition Tool)

Readily available

CONCUSSION ASSESSMENT TOOLS

King Devick Test: There's No Such Thing As A Tough Brain

Quick, Simple, Accurate King-Devick Test is an objective rapid

sideline screening test for concussions that can be administered by coaches, athletic trainers, medical professionals and parents in minutes.

King-Devick Test is an accurate and reliable method for identifying athletes with head trauma and has particular relevance to contact sports such as football, hockey, soccer, basketball and all activities.

Baseline testing http://kingdevicktest.com/

CONCUSSIONS

Evaluate for neck/facial injuries Often overlooked

WHAT TO DO

ANY SIGNS OR SYMPTOMS – NO RETURN TO PLAY

Send to Emergency Room if; Any loss of consciousness Any amnesia Any vomiting Any unusual behaviors If there is blood or fluid

draining from nose, ears, etc If signs / symptoms get worse

NEUROPSYCH EVALUATION

Baseline test Post concussion test Can be a valuable tool Not intended for sideline

testing

NEUROPYSCH TESTING What it is and what it isn’t

It is a tool to help determine recovery

It is a tool to help manage concussions

It is a tool to help communicate post-concussion status to coaches, parents, medical providers

It does not diagnosis a concussion

It is NOT a substitute for medical evaluation / treatment

What about the athlete who bumped their head & only has a headache and “saw stars” when they hit it?

Or who flat out lies to you about symptoms? Knowledge / Behaviors

How do you treat them in the heat of competition?

What’s your protocol?

SOME CONCUSSIONS ARE TOUGH TO RECOGNIZE

WHAT DO YOU DO?

Must recognize when a concussion occurs

May have to develop “quick check” strategies.

Need to use multiple evaluation tools

Remove the athlete with concussion symptoms or signs

Develop a method to communicate your findings to other health care providers

Educate your athletes, coaches, parents and administrators

WHAT DO YOU TELL YOUR ATHLETES & PARENTS?

What a concussion is … a brain injury

What signs & symptoms should they look for

When should they go to the hospital ER or MD

How they should take care of themselves

What the RTP protocol will be

What are the risks of returning before they are healed

When your protocol provides for their return to sports

Have a take home concussion care sheet

WHAT DO YOU TELL YOUR ATHLETES & PARENTS?

You DO NOT need to be “knocked out” to have a concussion

A concussion CANNOT be diagnosed by a CT scan, MRI or other imaging technology

CONCUSSIONS

Concussions may be cumulative & may have long term effects

Younger athletes take longer to recover & are more susceptible to 2nd impact syndrome

Girls seem to have more concussions than boys

Girls seem to take longer to recover than boys

Importance of Proper Care

No return to activity until symptom free

Graded return to activity

10 – 20% of concussions take longer than 7-10 days to resolve

“Post Concussion Syndrome”

May be very frustrating to all

Sleep disorders

Noise or light sensitivity

Dizziness

Headache

Difficulty concentrating

Effects on school or work

Evaluation

Rehab activities?

Medication

EXTENDED SYMPTOMS

RETURN TO PLAY

Must be symptom free

Must have zero signs

Must be cleared by a physician

Graded RTP protocol

Progressively increase exercise levels

6 step/day process

RETURN TO PLAY

Physical Activity Protocol NYS Guidelines

Phase 1- low impact, non-strenuous, light aerobic activity such as walking or riding a stationary bike. If tolerated without return of symptoms over a 24 hour period proceed to;

Phase 2- higher impact, higher exertion, and moderate aerobic activity such as running or jumping rope. No resistance training. If tolerated without return of symptoms over a 24 hour period proceed to;

Phase 3- Sport specific non-contact activity. Low resistance weight training with a spotter. If tolerated without return of symptoms over a 24 hour period proceed to;

Phase 4- Sport specific activity, non-contact drills. Higher resistance weight training with a spotter. If tolerated without return of symptoms over a 24 hour period proceed to;

Phase 5- Full contact training drills and intense aerobic activity. If tolerated without return of symptoms over a 24 hour period proceed to;

Phase 6- Return to full activities without restrictions.

Progressive Physical Activity Program

NFHS Guidelines

Step 1: Light aerobic exercise- 5 to 10 minutes on an exercise bike or light jog; no weight lifting, resistance training, or any other exercises.

Step 2: Moderate aerobic exercise- 15 to 20 minutes of running at moderate intensity in the gym or on the field without a helmet or other equipment.

Step 3: Non-contact training drills in full uniform. May begin weight lifting, resistance training, and other exercises.

Step 4: Full contact practice or training.

Step 5: Full game play.

Locust Valley School District RTP

Port Washington SD RTP

RETURN TO PLAY

What about….?

School work

Reading

Watching TV

Using a computer

Texting

RETURN TO LEARN

New emphasis

Difficulty returning to school/work

Extended symptoms

Class difficulties

Reading/Homework

Test/Quizzes

RETURN TO LEARN

RTL Strategies

RTL team

Family team

Medical team

Academic team

Physical activity team

Educational plan

IEP – for chronic conditions

504 – for accommodations for temporary conditions

REAP Concussion Management Program

WHAT ARE THE RISKS?

Second Impact Syndrome Athletes who return to sports

to early – while the brain is still healing – are at a greater risk for a more severe second concussion.

Second, or later, concussions can cause death or serious brain damage that may last a lifetime.

Post Concussion Syndrome May last months

Can you share with us how you manage your concussions?

WHAT ARE YOU DOING?

USAToday.com

http://www.cdc.gov/TraumaticBrainInjury

http://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/After-a-Concussion-Students-Need-a-Gradual-Transition-Back-to-Academics.aspx

https://www.aan.com/Guidelines/Home/ByTopic?topicId=13

http://www.nfhs.org/SportsMed.aspx

http://www.momsteam.com/health-safety

http://www.lawatlas.org/preview?dataset=sc-reboot

http://bjsm.bmj.com/content/47/5/250.full

http://www.rockymountainhospitalforchildren.com/sports-medicine/concussion-management/

www.NATA.org

Your state associations

RESOURCES

THANK YOU